Payment confusion: How a Medicaid rate gap squeezes some doctors

Dr. Raj Miniyar, a Rome pediatrician, opened a new practice in nearby Trion a year ago.

That office became the only pediatric practice in Trion, in the center of a rural county in northwest Georgia where 28 percent of children live in poverty.


Miniyar says that when he sees a Medicaid patient for an ear infection in Trion, the government insurance program pays him roughly $40. But if he sees a child covered by Medicaid for the same ailment at his Rome practice, he’ll be paid about $70.

The pay differential for doctors exists across Georgia, even though the state’s Medicaid patients are all covered by the same program.

“There’s no logic behind it,’’ Miniyar says.

It’s not clear exactly how many Georgia physicians are affected by the payment gap. But those who are affected say they’re frustrated. The problem discourages doctors from expanding their practices and serving Medicaid patients, they say.

The roots of the issue date back a few years, when the Affordable Care Act raised the pay rates nationwide for primary care doctors treating Medicaid patients.

To get the pay bump, physicians had to “attest’’ in the years 2013 and 2014 that they practiced in pediatrics, family medicine or internal medicine and were board-certified. The reimbursement boost was funded entirely with federal dollars.

The ACA pay hikes were phased out at the end of 2014.

Starting in 2015, the Georgia Medicaid program, with state funding, restored higher pay rates for some medical visit codes, then added more the following year. But if doctors had not attested during 2013 and 2014, they couldn’t get the pay bump.

And location matters. If physicians move to another city or work in a different office from where they “attested,’’ they can’t get the added pay in the new location.

That’s why Miniyar has been getting less in Trion and in Cedartown, where he also has opened an office.


He serves mostly kids on Medicaid and PeachCare, programs that often find it difficult to attract physicians to serve patients because of the low reimbursement.

“It doesn’t make sense, for someone expanding their services,’’ Miniyar says. “They should be rewarding us, not punishing us.”

Medicaid covers roughly 2 million Georgians.

The attestation problem also affects some subspecialists, as well as nurse practitioners and physician assistants seeing Medicaid patients.

Dr. Platon Collipp, a pediatrician in Jesup, said a nurse practitioner in his practice can’t get paid the higher amount, either, which he says adds to the challenges of rural providers. “It’s harder to recruit because it’s a rural area,” Collipp says.

Budget constraints

The state’s Medicaid director, Linda Wiant, said Wednesday that the program, in making the rules for the pay hike, “worked within the budget guidelines we had.’’


The agency has recently allowed doctors new to the state after Jan. 1, 2015, to attest and obtain the higher rate, Wiant said. But that doesn’t address the problem when doctors move within the state.

Lawmakers need to appropriate another $13 million annually to resolve the attestation problem, according to the Medicaid agency, the Department of Community Health.

The Georgia House of Representatives added about $6.5 million into the pending fiscal 2018 budget to address the problem, but that raise wouldn’t kick in till January. The Georgia Senate has cut that amount further still.

Dr.  Ben Spitalnick, president of the Georgia chapter of the American Academy of Pediatrics, said that by agreeing to the general Medicaid pay hikes, the Legislature and Gov. Nathan Deal helped rural health care and stabilized the doctor workforce in primary care.

“And we are deeply appreciative of those actions — I can’t stress that enough,’’ Spitalnick said. “But then to have a practice get their reimbursement cut by 40 percent because they opened a second office or changed locations or simply didn’t attest for the ACA increase three years ago for whatever reason, makes no sense.’’


The pay problem is a thorn in the side of Dr. Alison Ball, a young pediatrician in Conyers.

Ball came to Georgia in 2014, after completing her residency program, and she became board-certified in the state the following year. But because she was not able to attest during the designated time frame, she doesn’t get the higher pay to treat Medicaid patients.

Yet the other pediatricians in the same practice, Ball says, get the higher amount because they attested.

“It’s definitely frustrating,’’ she says. “If I go anywhere else in Georgia and [treat] Medicaid patients, I’ll get paid less.”